Proactive Care Lead, High Intensity Service Users

Proactive Care Lead, High Intensity Service Users

NHS AfC: Band 8a

Main area Community Services Grade NHS AfC: Band 8a Contract Fixed term: 12 months (Secondment will be considered for internal candidates – If you are successful after interview, you must obtain approval from your current line manager to accept the offer.) Hours Full time - 37.5 hours per week Job ref 218-NM-B8A-8359961

Site Enterprise Centre Town Coventry Salary £57,528 - £64,750 per annum Salary period Yearly Closing 25/10/2026 23:59

Job overview

Are you passionate about improving outcomes for people with complex health and social care needs? We are seeking an experienced and motivated Proactive Care Lead to identify, coordinate and support high intensity service users who frequently access healthcare services. You will work collaboratively across primary care, community, acute, mental health and voluntary sector partners to develop personalised care plans, reduce health inequalities, and promote independence. The successful candidate will demonstrate strong leadership, excellent communication skills, and a commitment to delivering person-centred care. This is an exciting opportunity to drive innovation, improve patient experience, and support sustainable healthcare delivery across the system.

A full UK driving license is essential for this post. Please note that an international driving license is not accepted.

Secondment will be considered for internal candidates – If you are successful after interview, you must obtain approval from your current line manager to accept the offer.

Successful applicants will be required to provide an immunisation and vaccination report, from either their current UK occupational health provider or their UK GP.

Main duties of the job

• Proactively identify and support high intensity service users who frequently access acute, community, primary care, urgent and emergency care services, ensuring their needs are assessed holistically and managed through coordinated care planned.
• Undertake comprehensive assessments of individuals with complex health, social, psychological, and behavioural needs to understand the factors contributing to high service utilisation and identify opportunities for alternative approaches to care.
• Develop, implement, and regularly review personalised care and support plans that promote self-management, improve health outcomes, and reduce avoidable healthcare attendance and admissions.
• Work collaboratively with multidisciplinary teams, including acute, community, primary care, mental health, social care, and voluntary sector services, to coordinate appropriate interventions and ensure seamless care delivery.

Working for our organisation

University Hospitals Coventry and Warwickshire NHS Trust, rated as good by the Care Quality Commission, is one of the largest teaching Trusts in the UK.

We are extremely proud of our employees across our hospital sites, with high quality patient care at the heart of everything we do.

Boasting some of the most modern facilities in Western Europe, the Trust is renowned for being at the forefront of research and innovation as part of its blossoming reputation as a worldwide leader in healthcare.

By joining our exciting journey, you will form part of a passionate, talented team and will be able to access a wide range of learning and development opportunities. There has never been a better time to join our team.

The Trust is committed to building an organisation that makes full use of the talents, skills, experience, and different perspectives available in our diverse society. We want everyone to feel they are respected, valued, can achieve their potential and receive the most appropriate and relevant care. We will create an environment where the equality and human rights principles of fairness, respect, equality, dignity and autonomy are promoted and are part of the organisation's core values.

Detailed job description and main responsibilities

• Proactively identify and support high intensity service users who frequently access acute, community, primary care, urgent and emergency care services, ensuring their needs are assessed holistically and managed through coordinated care planning.
• Undertake comprehensive assessments of individuals with complex health, social, psychological, and behavioural needs to understand the factors contributing to high service utilisation and identify opportunities for alternative approaches to care.
• Develop, implement, and regularly review personalised care and support plans that promote self-management, improve health outcomes, and reduce avoidable healthcare attendance and admissions.
• Work collaboratively with multidisciplinary teams, including acute, community, primary care, mental health, social care, and voluntary sector services, to coordinate appropriate interventions and ensure seamless care delivery.
• Act as a key point of contact for high intensity service users, providing case management, advocacy, and support to navigate services and access the most appropriate care pathways.
• Identify patients who may benefit from receiving care in alternative settings, such as community services, primary care, outpatient clinics, or other specialist support services, ensuring care is delivered in the most appropriate and least restrictive environment.
• Monitor patterns of service utilisation and identify trends, risks, and opportunities for intervention to improve patient outcomes and reduce unnecessary demand on healthcare services.
• Support the development and implementation of strategies, pathways, and initiatives aimed at improving care for high intensity service users, reducing health inequalities, and promoting integrated care across organisational boundaries.
• Maintain accurate records, collect relevant data, and contribute to service evaluation, quality improvement, and reporting requirements to demonstrate outcomes and inform future service development.
• Build effective relationships with patients, carers, families, and partner organisations to promote person-centred, coordinated care that improves patient experience and quality of life.

For further details of the role please see the attached job description.

Qualifications

• Registered healthcare professional (RGN, HCPC or equivalent professional registration). Independent prescribing and Advanced Health assessment qualification or expectation to complete within the first 12 months of being in post Degree-level qualification or equivalent experience. Evidence of continuing professional development. Leadership and management qualification or equivalent experience. Master's level study or working towards Master's level qualification, or equivalent experience. Training in quality improvement, service redesign, population health management or personalised care.
• Coaching, mentoring or supervision qualification. Project or programme management qualification. Teaching and assessing qualification. Coaching qualification

Experience

• Significant experience within community, primary care, integrated care or neighbourhood services. Experience leading multidisciplinary teams and managing change across organisational boundaries. Experience of service transformation and implementation of new models of care. Experience developing and delivering personalised care and support planning. Experience of partnership working across health, social care, voluntary and community sectors. Experience of leading quality improvement programmes and service evaluation. Experience managing complex clinical or operational situations
• Experience of working within an Integrated Care System. Experience of Population Health Management approaches. Experience of securing and evaluating programme outcomes

Knowledge

• Extensive knowledge of personalised care, proactive care and anticipatory care approaches. Understanding of integrated neighbourhood working and place-based care models. Knowledge of clinical governance, safeguarding and risk management. Understanding of current NHS policy, integrated care and neighbourhood transformation agendas, National neighbourhood health programme Knowledge of reducing health inequalities and addressing wider determinants of health.
• Knowledge of population analytics and outcomes measurement. Knowledge of research and evaluation methodologies. Experience of admission avoidance, anticipatory care planning, personalised care and support planning, and proactive interventions to improve patient outcomes. Experience developing, implementing and evaluating personalised care, proactive or population health management approaches/risk stratification.

Skills

• Strong strategic and operational leadership skills. Excellent communication and influencing skills. Ability to build effective relationships across organisational boundaries. Ability to analyse and interpret complex data and information. Ability to develop policies, pathways and service standards. Skilled in presentation, facilitation and report writing. Ability to manage competing priorities and deliver agreed objectives. Strong problem-solving and decision‑making skills. Competent IT and digital skills. A full UK driving license
• Advanced project management skills. Experience of workforce development and educational programme design.

Commitment to Trust Values and Behaviours

• Must be able to demonstrate behaviours consistent with the Trust’s values. (As detailed in UHCW’s Values in Action document below) Applicants applying for job roles with managerial responsibility will be required to demonstrate evidence of promoting equal opportunities through work experience

To ensure that we provide world‑class patient care, UHCW recruits people that can demonstrate the Trust’s Values and Behaviours in their everyday life. Therefore, if you are invited to interview, you will be undertaking a Values Based Interview/Assessment, which explores not only what you do but how and why you do it.
Before applying, we encourage you to review the Trust’s Values and Behaviours which can be accessed on the right side of this page under the job description.
The Supporting Information Section in your application should therefore reflect your understanding of the Trust’s Values and associated Behaviours. You will be expected to provide us with examples from work experience and/or personal life which demonstrate these values through your behaviour.

The Trust is committed to Equal Opportunities within the workplace. All vacancies will be considered for Job Share unless otherwise stated. All applicants who have a disability and who meet the minimum criteria for the job will be interviewed. Where a post has an overwhelming response, this Trust may use random selection in order to reduce numbers to interview, any disabled applicants will automatically be guaranteed an interview and will be exempt from this process.

In submitting an application form, you authorise University Hospital Coventry & Warwickshire NHS Trust to confirm from your previous or current NHS employer and other prior employers; previous NHS service details and personal data held about you, including Occupational Health data (inoculations and screening tests). This data will be transferred using NHS Electronic Staff Record and third‑party systems via an automated process and only used for the purposes of obtaining and maintaining accurate employment records, should you be appointed to the post.

UHCW NHS Trust, by virtue of its Green Plan, is committed to ensuring that the way we provide services minimises the impact on the environment and the future health of the public e.g. zero waste to landfill, reducing our carbon footprint and increasing our recycling and reuse percentages.

If you are successful at interview you will receive a conditional offer of employment and we’ll ask you for information so that we can carry out pre‑employment checks. You must successfully complete all pre‑employment checks to progress to a final unconditional offer.

We must confirm the identity of our staff and their right to work in the United Kingdom. We will ask you to submit proof of your identity and right to work documents via a secure digital platform approved by the Home Office, named TrustID. Alternatively, you may be asked to attend our office with original documents.

Depending on you level of exposure with patients you may be required to undertake a Standard or Enhanced DBS. The cost of this check will be charged to you and will be deducted from your salary over the first 3 months of employment at the current rate.

All correspondence will be sent by email; please check your account regularly including your Junk/SPAM folders

Employer certification / accreditation badges

You must have appropriate UK professional registration.

This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.

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